Traditional Play for Therapeutic in Chronically Ill Children

Transcription

1 Traditional Play for Therapeutic in Chronically Ill Children Abstract 32 Thanattheerakul C., PhD Assistant Professor Faculty of Nursing Khon Kaen University Khon Kaen, Thailand. Tangvoraphonkchai J., PhD Associate Professor Deputy Director Research and Training Center for Enhancing Quality of Life of Working-age People Faculty of Nursing, Khon Kaen University Khon Kaen, Thailand. This research was to study how to develop and sustain traditional play for hospitalized child patients. The study was conducted in a participatory action research which based on phase-to-phase development, the characteristics and contexts of the sample group. This preliminary study was completed in two phases. The first phase was the data collection from 12 nurses by question, What is the present situation of admitted child patients play activities? The second phase was the data collection from 25 hospitalized child patients and/or their parents by questions, What are the problems and need of these children and their parents related to the play activities at the hospital? and How should traditional plays be organized for these children? The findings reflected that play activities were organized by a hired teacher and could not be provided for all age groups. Parents should be informed of the importance of such activities for their children both their healthy and unhealthy status. While traditional play is challenge to perform for these children, and their parents reflected positively appreciated because of related to Thai culture context. Key words: traditional play, play activity, chronically ill children, hospitalized child patient, sick children. Introduction Presently, when children especially those with chronic illness are admitted into a hospital, their ability to play is limited. A question is sometimes raised as to whether a sick child can enjoy playing activities while being hospitalized. In general, people tend to forget that children s play is an important daily activity. Nurses cannot deny that one of their independent duties is the promotion of a child patient s play. They should see that such activity exists, and help it develop so that it responds to the sick children s satisfaction and their basic needs. Certain empirical studies found that play activities have a positive effect on the sick children and their families. The study by Chaikhun (2001), for instance, revealed that sick child patients participating in playing activities were able to cope with tension and pain better than sick children who had not been provided the opportunity. Although there have been studies that reflect the usefulness of play activities on sick children, at present no researchers have conducted a study to promote the thinking and roles of nurses to organize sustainable playing activities for their sick children so that the children can continue to enjoy their time in the hospital. Sick children s play activities in hospitals at present still lack continuity and true organizers. Usually, nurses or a hired teacher arranges the activities, where the patterns are not stable and depend on organizers free time from their regular routine. Problems exist for example, when the nurses who arrange the activities are not free, the activities are cancelled. In fact cancellation should not be the end answer because many studies have confirmed the efficiency of sick children playing. Therefore, the researchers were determined to develop sustainable play activities for chronically ill child patients and introduce Thai identity in the traditional plays into these activities with assistance from the hospital health team personnel. The activities, when arranged, would promote relationships between the child patients, their parents, and hospital staff.

2 Centre for Promoting Ideas, USA The study was based on participatory action research in order to locate problems and needs of sick children and their families. The results would be useful for determining appropriate ways to organize traditional play activities for child patients. Aims 1. Study the present play activities of admitted sick children at the pediatric wards. 2. Study the problems and needs of the sick children and their families related to play activities when they are admitted to the pediatric wards. 3. Study the possibilities of organizing traditional play activities at the pediatric wards. Methods Study design The research was conducted through the action research method and through mutual collaboration approach research. The parents and/or sick children, nurses, and related hospital personnel were asked to join in activities together in order to help develop sustainable traditional play activities for hospitalized children. Sample groups The major sample group consisted of sick children who were diagnosed by physicians as having a chronic illness and were admitted in wards 2D and 3D including caregivers from their families who came to take care of the children. The samples were purposively selected according to the following inclusive criteria: 1. The child patient had been diagnosed as having a chronic illness and was admitted in either ward 2D or 3D. 2. The child patient was 8 days to 15 years of age, which is the admission criterion of wards 2D or 3D. 3. The child patient s hometown was in the Northeast. 4. The child patient gave consent to participate in the research. 5. The child patient s parents or caregiver taking care of the child at the hospital gave consent to participating in the research. The second target group comprised nurses whom taking care of chronically ill child patients in wards 2D and 3D, Srinagarind Hospital. Collecting data was performed between December 2006 and December Procedure Phase 1 The study of wards 2D and 3D s conditions to understand the background of traditional play organization for the hospitalized children. The use of evaluation tool for the arrangement of the activities by the nurses was also investigated in order to measure the readiness or limitations in improving the sick children s activities. A non-participatory observation form was used in interviewing the ward head nurses along with group discussions with 5 nurses from each ward totaling 10 nurses. Phase 2 The study of wards 2D and 3D s conditions to understand the background and situation of traditional play organization for child patients. The use of an evaluation tool for the arrangement of the activities by the children s family members was also investigated in order to measure the readiness or limitations in improving the sick children activities. The needs of the child patients of all age levels (8 days to 15 years) and their families were surveyed using a participatory observation form, an in-depth interview, and group discussions with 5 child patients and their families from each age group. Phase 3 The use of the information collected from the study of situations related to traditional play organization in the view of the nurses, the sick children and their families to build a play activity model for hospitalized child patients. The model was then presented to the patients and their families at wards 2D and 3D before the experimental stage. Phase 4 The experimenting of the traditional play activity model constructed with 5 children from each age group following the action research cycle which comprised: 33

3 1. Implementation and observation The traditional play activity model was implemented with the child patients and their families, and the results assessed. 2. Reflection The nurses in charge met with the child patients families and the researchers after implementation in order to reflect the problems, obstacles, and means to solve the problems. 3. Model improvement The researcher team met every week and conducted discussion groups with nurses, child patients and their families in order to improve or modify the traditional play activity model and make it more efficient. The phase cycle was repeated until the information collected was stable. Then the results were concluded into the final traditional play activity model for hospitalized chronically ill children. Data analysis The researchers analyzed the obtained information after the implementation of the traditional play activity model at wards 2D and 3D every Wednesday and Friday. Total data analysis was conducted by the researchers, ward heads, and nurses every week. The data were qualitatively analyzed by classifying them into different categories, and similar, different, or contrasted data were compared in order to find the common answer. The similar data was organized as data to be developed into a play activity model for chronically ill child inpatients. Ethical approval Ethical approval was obtained from both the hospital and the University Human Research Ethics Committee, Institutional Review Board of Khon Kaen University. The members of the study team explained the purposes and procedures of the study to the subjects before they agreed to participate in this study. There were no risks to the subjects. The participants could withdraw from the research any time they wished. Results Following is the research findings: 1. Conclusion of the in-depth interview conducted with the two ward heads: 1.1 Policy supporting play activities Ward heads reported that the hospital had a policy to organize play activities for child patients, but there was no written order or details for the operation principles. There was a policy emphasizing holistic child patient care which included child patients play. The head nurse of ward 2D said, Playing is a child s life, while the head nurse of ward 3D said, Playing is the heart of a holistic child care. There was an emphasis on instilling the importance of integration of child play activities in nursing. The head nurse of ward 2D reported, I emphasize the 3P which is the nurse s independent role, i.e., pain, play, and palliative care. I always ask my staff how many Ps each one has done each day, and if the action has been recorded and assessed. Additionally, it was found that at both wards, a designated nurse organized play activities, with the ward head acting as the supervisor. 1.2 Problems and obstacles in arranging play activities at the wards The ward heads reported a similar problem and obstacle in the play activities, namely, the individuality of the nurses. The 2D ward head nurse said, Each nurse is different. I can only tell them. It depends on each one s belief if it is important, and each one s art skill and creativeness. The 3D ward head nurse also had the same opinion, Each nurse has different techniques and gives different levels of importance to the play activities. Furthermore, the shortage of staff to deal with various work-related tasks affected nurses abilities to organize play activities for sick children. In addition, play activities were limited by patients conditions. The head nurse of ward 2D reflected, Play activities in ward 2D are difficult because the children have different diseases and their age levels are all different. Most of them are in serious conditions. Only those not suffering severe conditions are able to join. I always tell the nurses to provide play activities for the children, but they could not do this on a regular basis due to their patients limitations and nurses time constraints in caring for severe cases. Another obstacle at ward 2D was the absence of a space designated for play activities. There was no specific room set aside for this purpose, while the rooms in the wards had been usually used for medical or nursing students. 34

4 Centre for Promoting Ideas, USA The characteristics of play activities held in pediatric wards Generally, a hired teacher organizes play held in the two pediatric wards. Nurses only support and coordinate work for effective operation. The time table of the teacher is on Friday afternoon for 2D ward and on Wednesday afternoon for 3D ward. The head nurse of ward 2D added: People outside may wonder why nurses do not take the role in arranging the child play activities, but leave it to the teacher. In fact, I myself proposed recruitment of an extra teacher to arrange activities for the sick children under supervision of the nurses. Now, I supervise different projects organized by the teacher and the parents. After setting up responsible staff, the child play activities are satisfactory among the parents. What still needs to be improved is individual play activities for 2D children, where the teacher is still not able to do it because of lack of understanding. So I have encouraged my nursing staff to work with the teacher and try to organize such activities so that the role of nurses will be more evident. If the administrators see the importance of child patients play, which makes the children and their family happy, we may be able to ask for more nurses to help arranging such activities. 1.4 Opinions towards traditional play activities The head nurses of both wards believed that traditional play activities are good because they have been inherited from the past. Traditional playing relates to ways of living and local culture. The playing kits can be easily obtained in the locality. There are many plays in Isan. If these are used for the therapeutic activity, the children should be happy. At the same time, the activities that children like will enhance the children s growth, thinking, and concentration. The new generation will also be exposed to local culture and tradition. Now, at ward 3D, traditional activities have been integrated such as Mor Lam singing. The 3D head nurse said, Some children enjoy it. But teenagers like other styles. Bringing traditional activities for the therapy may be complicated at the beginning. However, if we do not try, we wouldn t know. I think the problem lies in the shortage of staff. We have to think of many children who get tired easily and select the activities accordingly. Additionally, the knowledge of traditional playing may be new to the children. We have to select what they are interested in. It should be good. 2. Results from group discussions with 10 nurses from wards 2D and 3D: 2.1 Policy supporting play activities - nurses voiced their opinions related to the policy for the play activities. They saw that the policy of the ward was clear and the ward head nurses emphasized that such activities should be one duty of nursing. All nurses were aware and informed that playing is important to child patients. I am well aware that playing is the heart of children, especially sick children, for it lessens their stress and torment. (the 3 rd nurse, ward 3D) 2.2 Problems and obstacles in arranging play activities at the wards Even though the operational policy has been clearly set, the group discussion revealed certain aspects opposing the arrangement of the activities. This can be concluded from the highest to the lowest degrees as follows: Child patients characteristics All of the nurses agreed that the conditions of the child patients were the causes of unable to provide the play activities at the ward. It is difficult to arrange play activities because child patients are suffering severe conditions, the diseases are various, and the nurses are loaded with work to the point that we are not able to lead the children to do activities. (the 1 st nurse, ward 2D) Most of the child patients in ward 2D are under severe conditions. We don t know what kind of activities we should come up with. (the 2 nd nurse, ward 2D) To tell the truth, I participate very little in the children s play activities because most of the time I have to care for serious patients, and don t have time to arrange any play activities for others. (the 3 rd nurse, ward 2D) Work load and shortage of staff All of the nurses agreed about the great workload and shortage of nurse staff. I confess I rarely carry out the assigned work on arranging the child play activities. During my shift, there is a lot to do. The child patients here are toddlers in severe conditions. I don t know what to arrange for them. (the 2 nd nurse, ward D) 35

5 Even though I m informed and aware of the importance of a child s play, it is difficult to carry out. Caring of the patients in Team 1(for severe condition patients) is a hard job. And I see that the play activities are arranged by the hired teacher. Mostly it is the child patients in Team 4 (for chronic condition patients) who can join. The patients in Teams 1-3 cannot play, but I see the hired teacher brings the playing kits for some cases to play on their beds. As I have observed, some didn t play. (the 3 rd nurse, ward 2D) I rarely arrange any play activity for the children because I m very busy with regular work. (the 3 rd nurse, ward 2D) Playing kits and moving of building Both wards 2D and 3D were temporarily moved from the old building to the new 19-storey SW Building. The moving resulted in problems related to storing and using of tools and playing kits. One nurse reported, I can say that after we moved here, we rarely arrange any play activity for the child patients. It looks like we re busier, even though the nurses roles seem to be reduced. Mostly, The hired teacher arranges the activities. The playing kits are kept by hired teacher in her car. Formerly, she held the play activities on the children s beds according to each child s want. I think that is good. But now, the hired teacher arranges group activities for the parents, such as doing art work, which I think does not fit the children. Usually, Team 4 joins the activity on Fridays. But even though I m in Team 4 I m not free. I have to help other teams. (the 5 th nurse, ward 2D) From the above discussion, we can see that the play activity was not effective because of lack of readiness of playing kits and limitations of the activities. The younger child group was not provided with the play activities that would meet their age level. Instead, activities were arranged for parents or caregivers to reduce their tension. 2.3 Patterns of play activities at the pediatric wards The group discussions conducted with 10 nurses on the play activities arranged for the child patients at present showed similar results as what obtained from the in-depth interview with the two ward head nurses. It was found that the hired teacher was the main organizer of the play activities. Nurses only supported and coordinated for effectiveness of the implementation. The activities by the teacher were held for all groups on Friday afternoons at ward 2D and on Wednesday afternoons at ward 3D. The nurses recommended an interesting solution to the play activities, On-duty nurses do not have time to arrange any activity. We should get the off- duty nurses to help arrange the activities. However, this can only be done during certain weeks. (the 2 nd nurse, ward 3D) We can arrange the play activities efficiently at the ward if there is a clear policy set by the administrators. More staff and budget should be allocated. Responsible staff should be assigned on a regular basis like the hired teacher. If nurses are seen as appropriate to take this role, then the shifts should be planned accordingly. (the 3 rd nurse, ward 2D) 2.4 Opinions towards traditional play activities Nurses from the two pediatric wards believed that traditional plays were inherited from the past and are related to the ways of living of the people, beliefs, and local culture. The playing kits can be found in the locality. Traditional plays may include puppet shows that relate folk tales, snake s tail play, mon sawn pha, ma kan kluay (banana stalk horse), mor lam. Most of the nurses believed these activities were challenging. If they could be part of the child patient activities in Isan, they would bring positive effects on the children. At least, they would be enjoyable. However, the activities should be appropriate for the sick children especially in the group whose physical conditions may limit their movements. 3. Conclusion from the non-participatory observation of play activities in the wards Most of the play activities arranged in the two wards were individual and depended on the conditions of the patients and the relatives. The nurses only coordinated and supported them. The major organizer was the hired teacher who would arrive at the ward when it was known that a child was ready to play. The teacher also designed the activity. These activities were arranged twice a week. At ward 3D, it was held on Wednesdays and at ward 2D, it was arranged every Friday. The health team staff responsible for the activities included the hired teacher, nurses, and nurse aides. The nurses joined in on the activities occasionally. The suitable time for the activities was the afternoon from 2 to 3.30 p.m. The length of time spent on the activities ranged from one to two hours. 36

6 Centre for Promoting Ideas, USA 4. Information from in-depth interview with child patients families classified by the children s age groups 4.1 Infant group Following is the arrangement of traditional play activities for this group: The hired teacher was responsible for all plays in which the patients families were encouraged to participate. Most activities both for individuals or groups, however, suited older age children better. Most of the infant caregivers were not able to join the activities for they were giving bedside care to the infant patients. Wednesday was the activity day. The nurse would screen the child patients and families to join the activities. Now, the activities are arranged by the hired teacher. Parents also join the activities. The activities are enjoyable, the children have fun drawing pictures, blowing balloons, etc, But I rarely join the activities because most of the time I care for my baby at the bed. (Mother of the 1 st child patient) Mostly I see the hired teacher led the activities. Nurses only participate when they are free. The activities include playing with toys brought by the teacher, coloring pictures, drawing. Parents join art activities. I think the activities do not suit all the children. For example, the singing activity cannot be joined by infants. (Mother of the 5 th child patient) Two out of five caregivers stated that the play activities were not suitable to infant patients. They believed the activities should enhance growth according to the age level. They should enhance development of children such as bell ringing, talking with the child, working out for the child. (Mother of the 1 st child). Two out of five of the caregivers suggested the activities should create income for the family. The activity should not be dangerous to children and would be good if it can build some income for the family. (Mother of the 5 th child patient) The traditional play activities at the wards were not arranged systematically. However, all see the benefits and necessities of traditional play. Caregivers of the infants in this age group believed the following traditional plays were suitable for the infant patients: hanging tapian fish, hanging woven grasshopper, sounding bell in takraw. Three mothers out of five said they did not know about traditional plays that would be good for their babies The important obstacles to traditional play activities as seen by the caregivers were the limited space of the place, the condition of the children and timing, which would not allow the caregivers to join in the activities at the ward. 4.2 Toddler group Following is the arrangement of traditional play activities for this group: The hired teacher was responsible for all plays, and the patients families were encouraged to participate. Most activities were for older age children and they were for both individuals and groups. Most of the toddlers, 4 out of 5, were able to join the activities. They felt relaxed when participating. Many activities, like making flowers, origami, scarf crocheting, bird origami, are taught by the teacher to the children and the parents. Sometimes grandmothers also join. It s fun. (Mother of the 8 th child patient) Four out of five toddler caregivers stated that the activities for this age group should encourage the babies to play in a wide area with children of the same age level. The health personnel team should include nursing students, who can help explain rules to the toddlers. The activities should include coloring pictures, playing with cartoon idols, playing with toy cars, playing with guns, listening to tales, playing with tapian fish, playing with sound toys The arrangement of traditional play activities was not concrete. Everyone concerned that traditional plays are good and necessary for child development. The plays seen suitable to the toddler patients included: riri khawsan, mon sawn pha, snake s tail, ka khap khai, kha thok thek, mak kep, ten yang, siangtam sai, ma kan kluay, kite, kala (coconut shell) walking, hanging grasshoppers/tapian fish. 37

7 4.2.4 Obstacles to the arrangement of these activities were the same as the infant group. Caregivers in this group were also concerned about the safety of children. 4.3 Pre-school age group Following is the arrangement of traditional play activities for this group: The hired teacher was responsible for all plays, in which the patients families were encouraged to participate. Individual as well as group activities were included. Caregivers who could also join reflected that the activities were useful for the children. They enhance development, thinking, and imagination. (Mother of the 11 th child patient) They are important for children s brain development according to the age level. (Mother of the 12 th child patient) The children learn how to think and when they join their peers, they have fun. (Mother of the 13 th child patient) The children will have many friends, learn how to think and solve problems. (Mother of the 14 th child patient) Four out of five caregivers believed the activities suitable for this age group should promote free thinking and imagination such as role playing, coloring pictures, story telling, watching cartoons, and playing games The traditional play activities are not concrete. However, all of the research participants thought traditional plays should be useful for the children. Good. The children will know what children played in the past and the plays will be carried on. (Mother of the 13 th child patient) A mother was worrying about the most common type of play activity among children, i.e., computer games. Traditional plays have been forgotten and not promoted, even by adults. Some caregivers admitted they could not think of any such activities. We ve never organized it. It s good you raise this up. We never think we should arrange such activities when our child is admitted in hospital, not to mention the traditional plays. We spend our time caring for our child. (Mother of the 14 th child patient) The traditional plays thought suitable for this age group were ma kan kluay, mon sawn pha, snake s tail, kala (coconut shell) walking, riri khawsan, mak kep The obstacle to traditional child plays reported by most caregivers was insufficient space. Some said the concrete floor was not suitable for the children s safety. Next, some sick children were tired and weak and could not attend or join the activities. The caregivers said the nurses should help to create suitable play activities for the children so that they could join appropriately. 4.4 School-age group The traditional play activities arranged for this group can be concluded as follows: The hired teacher and the nurses cooperated to arrange the play activities at the ward and encouraged the patient families to join. There were both individual and group activities. Most of the school-age caregivers were able to participate in the activities and said the activities were useful, some of them even created incomes. The activities arranged are very good. The health care staff are interested and try to find activities that the children and their relatives can do together. The activities are enjoyable such as folding paper birds, doing art work. My child likes it when I do it. He joins me and likes the activities. (Mother of the 16 th child patient) There are many activities. The children and the parents enjoy them because they create income for us. (Mother of the 19 th child patient) Four of the five caregivers believed suitable activities for this age group should be those that the children are able to do, are interested in, and have freedom in doing them. For example: acting, drawing pictures, singing, playing games, coloring pictures, playing dominos, reading tales and game books The caregivers saw that traditional plays are not systematically arranged. Everyone thought traditional plays should be useful for the children. They must be good. The children will learn what the folk plays are like. (Mother of the 18 th child patient) Very good. The activities carry on local activities for more people to know. (Mother of the 16 th child patient) The suitable traditional plays the caregivers suggested included riri khawsan, mon sawn pha, ma kan kluay, kala (coconut shell) walking, pao kop (blowing rubber bands), tee jap, and len khai khong (trading play). 38

8 Centre for Promoting Ideas, USA The obstacles to doing traditional activities at the children s wards were the narrow space and the patients weak condition which prevented them from joining the activities. The caregivers, however, thought selection or setting of suitable activities was important in encouraging all the child patients to participate. 4.5 Adolescent group The traditional play activities arranged for this group can be concluded as follows: The hired teacher and the nurses cooperated in arranging the activities at the ward. The hired teacher took the main responsibility. The child patients families were encouraged to participate in both the individual and group activities. Most of the caregivers could join the activities with the child patients and reported that the activities were useful for the children and some even created incomes. One out of the five caregivers talked about the nurses roles which showed their attentiveness: The nurses have activities for the children. They come to chat, bring presents on important occasions. I think they pay attention to the children. (Mother of the 22 nd child patient) Most of the caregivers believed suitable play activities for adolescent patients should be those that they like and are interested in. In addition to other age groups, the activities should raise incomes, teach the children how to live with others in the society, teach them how to share, help others. The suggested activities included acting out, drawing pictures, singing, playing games, coloring pictures, reading books, playing video games, playing musical instruments, and doing art work The caregivers thought traditional play activities at the ward were not concrete, but saw that the activities are useful for children. They re very good. The children will learn that these are our traditional activities and become proud that they can play like their mother and father did in the past. (Mother of the 25 th child patient) It would be very good to have the plays for the children. They will know the folk cultures and the good Thai cultures. The activities should be arranged at the ward in order to carry on with the folk tradition and other people will be able to learn. (Mother of the 21 st child patient) The suggested traditional plays seen as suitable for this age group included mon sawn pha, tee jap, pao kop, ri ri khaw san, ma kan kluay The obstacles to arranging traditional play activities were narrow space and the patients conditions, such as receiving intravenous fluid. 5. Information collected from non-participatory observation with reference to play activities among the patients families at the wards Observation revealed that most patient families did not take major roles in arranging or creating play activities for the children. The main responsibility was given to the hired teacher. The activities arranged included both for individuals and for groups, which depended on the physical conditions of the patients and the readiness of their families. The nurses only coordinated and supported. It could be concluded that arrangement of play activities by the patients families at the hospital were not concrete. Some families had potential or knowledge to acquire toys for their own children. Some families did not see the importance of playing while their children were ill. However, the majority knew about the importance of children s playing, but did not know what to do. Therefore, the teacher took the major part in this job. As for the introduction of traditional plays in Isan context at the wards, the findings indicated that there were no arrangements of folk plays. Most of the play activities were initiated by the teacher. It was noted that most of the activities organized were suitable to older child patient. The activities made the sick children and their families enjoy themselves. Some activities could create incomes. Nevertheless, for younger age groups, the play activities were not concretely organized. Suggestions for further studies The research results provided information for the implementation of the next stage, which comprises: the present arrangements of play activities for the child patients admitted in the pediatric wards, the problems and needs of the sick children and their families related to the play activities. The latter includes three main factors, namely policy, personnel, and child patients families. The research participants, namely, ward head nurses, nurses, child patients families, provided similar perspectives for the organization of play activities for child patients at the wards. 39

9 They stated that the sick children had certain limitations preventing them in joining the activities such as weakness, severity of the diseases, and treatment equipment on the children. The head nurses of the wards and nurses shared similar opinions in terms of policy, i.e., they focused on the importance of play activities for sick children, and problems and obstacles in implementation. The head nurses thought the most important component in provision of play activities was the nurses, while the nurses thought the most important issue was child patients physical limitation. The child patients families emphasized that two age groups were unable or rarely joined the activities: the infant and toddler groups, as shown in Figure 1. Traditional play activities at the pediatric wards were found to be a new idea and positively appreciated. However, the play activities arranged at the present time still have many gaps. Introduction of something new necessitates careful consideration. Holistic view of the present play activities for the sick children showed that nurses were supporters and coordinators for the organization, and the teacher was the most responsible person. Most activities were arranged for older age children and the patients families, and they were emphasized on activities that could create incomes for the patients families, for example, making mock flowers, making hats or scarves, etc. Activities arranged included both individual and group activities depending on the conditions of the child patients. The relationships between the factors affecting play activities for the hospitalized chronically ill child patients viewed from this hospital are given in Figure 2. The situation of providing play activities in these two pediatric wards are set by the hired teacher mainly, while the nurses are the coordinator. Also, there are many factors affecting play activity for those children and causes of those factors are shown as in Figure 2. Conclusion Primary data analysis revealed that introduction of traditional play activities to the hospitalized chronically ill children could be possible in two age groups, namely the infant and toddler groups. The activities could be applied through the families or the caregivers to involve the children in the activities. It is expected that the activities would be beneficial for the young children and build relationships between the caregivers and the health personnel. The researchers therefore proposed a traditional play activity model for the two age groups as a pilot study to be considered along with the health care staff at wards before the third stage experiment, as shown in Figure 3. Discussion Since the pediatric wards have limitations that obstruct many play activities as can be seen in Figure 2, the policy should be adjusted in order to involve nurses as the main personnel to arrange the activities. The present solution was hiring a teacher to take charge in this job. Gaps have been found especially in failure to arrange activities for all age groups. The researchers see that infant and toddler groups should be given attention. If they lack encouragement by means of play activities when they are sick, their future growth and development will be affected. Parents or families should also be informed by the health personnel that children should be provided with opportunities to play both when they are normal and sick. If traditional play activities, which have not been done before, are to be implemented, they should be started at a small circle. Testing activities with an age group or two age groups would be discussed. However, the wards have to take this under consideration before implementation. The researchers have designed two models for arranging traditional play activities for two age groups as follows: Infant group 1. The infant s mother should be involved in the activities. 2. Traditional play activities should be suitable to the age and promote development at this stage. 3. The hired teacher should be given recommendations in arranging the activities, especially in selection of suitable activities. Toddler group 1. The toddler s mother should be involved in the activities. 2. Traditional play activities should be suitable to the age, promote development, and be safe. 3. The hired teacher should be given recommendations in arranging the activities, especially in selection of suitable activities for toddlers. 4. Books on traditional plays with illustrations should be acquired, or DVD players provided for toddlers to see the plays. Parents can also allow their children to play when they are discharged

10 Centre for Promoting Ideas, USA 3 Main groups plus one which affecting providing play activities for hospitalized Head nurses of pediatric wards 1.Convince the health care staff to concern the importance of providing the play activity for children 2.Problems and obstacles in arranging play activity at the pediatric wards Individuality of the nurses Type of patients Limitation of space for doing play activity Nurses at pediatric wards 1. Acceptance of play activity as one of nursing activities 2. Problems and obstacles in arranging play activity at the pediatric wards Type of patients: severity of chronic illness Work load Inadequate of plying kits and moving of building Individuality of the nurses to perform the play activity Child patients families 1.Most of play activities performing in the pediatric wards suitable for the family and children in older age, but not for infant and toddler groups. 2.Most of families need the activities that create income for the family. 3. Some families did not concern to perform the play activity for hospitalized children. 3. Problems and obstacles Type of patients Limitation of space for doing play activity Hired teacher arranges all play activities Play activities for hospitalized children Figure 1. Play activity situation in pediatric wards Organizers Factors affecting play activities in children at wards Causes Play activity Readiness of patients to join activities play activity Age Type of patients Hired teacher as the major responsible person for the play activities Unsuitable place for activities Readiness of health care staff Moving of building/ narrow space Shortage of suitable place Moving of building/ narrow space Shortage of suitable place Workload and shortage of staff Nurses as the coordinator for the play activities Play activity Activities not suitable for some age groups Play activity Lack of providing suitable play activity for infant & toddler groups No suitable play activity to enhance development for these two groups Figure 2. Factors affecting play activities in children at pediatric wards 41

11 GAP in traditional play activities in two age Infants Toddlers -Select the Involve mothers to provide the traditional play that enhance development according to Mother Unable to join due to take care the baby at the bed Activities held not suitable for promoting Mother suggested these suitable traditional plays: hanging tapian fish, takraw with a sound bell Child Unable to join due to limitation of age Mother suggests these suitable traditional plays: riri khaw san, mon sawn pha, snake s tail, ka khap khai, kha thok thek, mak kep, ten yang, siang tam sai, ma kan kluay, kite, kala walk, kicking takraw with a bell, hanging tapian certain play activities that are suitable for the sick children -Make DVD to introduce traditional plays for children and Figure 3. Piloting model for traditional play activities in two age groups References Thai children s plays Nov 4, [Nov 4, 2008] ; Available from: URL: Thanattheerakul, C Family-centered care: Challenging concept towards implementation in Thai society context. Khon Kaen University: Faculty of Nursing Journal, 26(3): Chaikhun, D Effects of Play Activities on Tension Coping Behaviors and Pain from Abdomen Operation of School Children. Child Nursing Thesis, Graduate School, Khon Kaen University. The Royal Institute Dictionary, Retrieving from p letter group [online] Jan 4, [Jan 4, 2009] ; Available from: URL: Potmak, P Effects of Play Program for Pre-School Children on Reactions when Separated from Mothers at Hospital. Child and Mother Nursing Thesis, Graduate School, Mahidol University. Soo-ampan, A Importance of Playing. Nov 4, [Nov 4, 2008]; Available from: URL: 50/child_ play002. html Association of Oncology Social Work. Association of Oncology Social Work and Association of Pediatric Oncology Social Work Joint Position on Family Centered Care. [online] September 28, 2004 [Oct 28, 2004]; Available from: URL: Coyne, I.T Parent participation: a concept analysis. Journal of Advanced Nursing. 23(4): Hutchfield, K Family-centered care: a concept analysis. Journal of Advanced Nursing. May, 29 (5): Johnston, C.E., Marder, L.R Parenting the child with a chronic condition: an emotional experience. Pediatric Nursing. Nov-Dec; 20(6) : Merriam-Webster Online Dictionary Merriam-Webster Online Search. [online] Jan 4, [Jan 4, 2009]; Available from: URL: Shelton, T.L., Stepanek, J.S Excerpts from family-centered care for children needing specialized health and developmental services. Pediatric Nursing; Jul-Aug, 21(4): Windham Community Memorial Hospital. Family-centered care. [online] 2004 [Oct 28, 2004]; Available from: URL: 42